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Efficacy of anterior stromal puncture surgery with corneal bandage lens for bullous
keratopathy
Guigang Li1, Jiao Zheng2,3, Jin Gong2,3, Alataree Sameer1, Xinyu Li1, Yuan Zhang4, Sean
Tighe4, Yingting Zhu4 and Ping Wang2,3
1Department of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong
University of Science and Technology, Wuhan, Hubei Province, 430030, China.
2Department of Ophthalmology, Renhe Hospital affiliated to Three Gorges University,
Yichang, Hubei Province, 443001, China.
3Eye institute, Three Gorges University, Yichang, Hubei Province, 443001, China.
4Tissue Tech, Inc., Miami, FL, 33126, USA.
Running title: Anterior stromal puncture for bullous keratopathy
Key words: anterior stromal puncture; bandage contact lens; bullous keratopathy
Author for Correspondence: Wang Ping, M.D. and Ph.D., Department of
Ophthalmology, Renhe Hospital affiliated to Three Gorges University, Yichang, Hubei
Province, 443001, China. Telephone: 13997712859; Fax: 86-27-83663688; E-mail:
[email protected]
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Abstract
Objective: To investigate the safety and efficacy of the combination therapy of anterior
stromal puncture (ASP) with bandage contact lens for bullous keratopathy (BK).
Methods: Twelve cases (12 eyes) with vision acuity no better than light perception were
treated with ASP surgery and bandage contact lens. 200 points punctures were made
through the corneal epithelium and Bowman’s layer vertically, using fine needles. A soft
bandage contact lens was applied immediately and removed 2 weeks later. The severity of
irrigating symptoms including pain, photophobia and tearing was graded and calculated
before treatment and 1, 2, 4, 12 weeks after the surgery, slit-lamp microscope examination
was used to quantify the time for corneal epithelial blisters disappearing, optical coherence
tomography (OCT) was used to monitor the central corneal thickness.
Results: No cornea infection was observed during the following up period. The average
grade scores of the irrigating symptoms was 8.3 ± 2.1 before surgery, while it was reduced
to 4.8 ±1.9 two weeks after the surgery (p=0.0003). Slit-lamp microscope examination
showed that corneal edema relieved obviously after the operation, the average time for
epithelial blisters disappearing was 15.6 ± 4.0 days. The average central corneal thickness
of the eyes was 999.3 ±278.0 μm before the treatment, while it was 805.1 ± 145.0 μm four
weeks after the treatment, with a statistically significant difference (p=0.043).
Conclusions: ASP with bandage contact lens is an effective and safe treatment for
patients with BK and low vision that not suitable for corneal transplantation.
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Introduction
Bullous keratopathy (BK) is the cornea pathology when corneal endothelial dysfunction
occurs due to various causes, in which fluid of corneal stroma and epithelium can’t be
pumped out properly, thereby forming a long-term edema, resulting in formation of blisters
in epithelium and sub-epithelium of the cornea [1]. It is a late manifestation of corneal
endothelial decompensation. In clinical, the causes of BK are including advanced age,
ocular trauma, diseases such as primary corneal endotheliopathies, absolute glaucoma
and endothelial cell loss due to surgical interventions such as penetrating keratoplasty
following graft failure, cataract surgeries and vitreoretinal surgeries with silicone oil
implantation [2-5]. Continuous and progressive cornea edema leads to visual acuity
decreasing. And rupture of the epithelial bullae can cause symptoms of severe ocular pain,
lacrimation and photophobia. It increases the risk of microbial infection [6-9].
Corneal graft is the definitive treatment for BK which can restore vision and provide pain
relief [10, 11]. For patients with poor visual function and no promising improvement of
visual acuity, or those who has limited economic capacity, the primary goal of treatment is
to relieve symptoms and restore normal ocular surface. Current treatment includes
medications, contact lens wearing, amniotic membrane transplantation, conjunctival flap
covering, penetrating keratoplasty and endothelial transplantation, however, each has its
own limitations [7-10, 12-14]. In 1965, Salleras described an alternative method termed
electrocautery of Bowman' s membrane for bullous keratopathy [15]. However, there were
also some complications related to this procedure, such as definitive corneal flattening,
corneal healing problems, intraocular pressure (IOP) increase and shortening of the
anterior chamber [15-17]. In this study, we observed the clinical efficacy and safety of
anterior stromal puncture surgery combined with corneal bandage contact lens in bullous
keratopathy.
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Methods
Patient information
This study was approved by the ethics committee of Tongji hospital, all of the treatment
was applied to the twelve eyes of Declaration of Helsinki, informed consent was collected
before treatment. 12 patients with bullous keratopathy were treated from March 2013 to
July 2017, 7 males and 5 females, aged from 47 to 84 (mean 64.3±9.8) years. Causes of
bullous keratopathy: 2 patients received vitrectomy combined with silicone oil implantation
for retinal detachment, 6 patients received phacoemulsification with or without intraocular
lens (IOL) implantation,3 patients received trabeculectomy for angle-closure glaucoma,
while the other one got bullous keratopathy from ocular trauma. All of the 12 patients had
irritation symptoms including recurrent eye pain, photophobia and lacrimation. Corneal
stroma was thickened and edematous with various density of gray haze, with intact or
ruptured corneal epithelial blisters. The vision acuity of the patients was below or equal to
light perception and the course of the disease lasted more than one year. Preoperatively,
all cases had used a variety of topical medications with no significant relief (Table 1).
Table 1 Demographic data
Case number Sex/Age Eye Vision acuity Cause of BK
1 M/62 OS LP Aphakia
2 F/63 OS NLP IOL
3 M/77 OD NLP Aphakia
4 M/62 OS NLP Glaucoma
5 F/58 OS LP Aphakia
6 F/63 OS LP Vitrectomy & Silicone oil
implantation
7 F/61 OS NLP Aphakia
8 M/47 OD NLP Glaucoma
9 M/56 OS NLP vitrectomy & Silicone oil
implantation
10 F/72 OD NLP Trauma
11 M/67 OS LP IOL
12 M/84 OD NLP Glaucoma
NLP: no light perception; LP: light perception;
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ASP surgery and bandage contact lens
ASP surgery was carried out under topical anesthesia. After sterilization and draping, the
diseased eyes were prepared for topical anesthesia with 0.04% oxybuprocaine, one drop
every five minutes for three times. Loosen central corneal epithelium was removed gently
using sterile cotton swab (when difficult to remove, it was not removed) under surgery
microscope. Number 30 insulin injection needles were used to make vertical punctures
through the corneal epithelium and Bowman’s layer, the depth was set according the
thickness measured with optical coherence tomography (OCT,Zeiss, German), with a
depth no less than half of the full thickness while penetration to be avoided. The total ASP
points were no less than 200, to make sure that punctured area could cover the corneal
epithelial blisters area, while the areas with normal cornea epithelium left intact. After the
surgery has been done, a soft bandage contact lens was applied immediately to reduce
irritation and pain. Post operation treatments including antibiotic (0.5% Levofloxacin eye
drops, qid), anti-inflammation (0.1% pranoprofen eye drops, qid) and basic fibroblast
growth factor gel to prevent infection and promote the healing of cornea epithelium. (Fig 1)
Figure 1. The procedure for ASP surgery, under topical anesthesia, No.30 insulin injection
needles were used to make vertical punctures through the corneal epithelium and
Bowman’s layer, the depth was set according the thickness measured with OCT and
restricted by needle holder (A and B). The total ASP points were no less than 200 (the
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surgery was performed into the entire cornea), to make sure that punctured area could
cover the corneal epithelial blisters area (C).
Post operation observation
Irrigating symptoms The irrigating symptoms including pain, photophobia and lacrimation
was graded according to the severity, that is serious, medium, mild and absent, scored 3,
2, 1 and 0 accordingly. The grades were tested before and 1, 2, 4 and 12 weeks after the
treatment.
Corneal epithelial blisters disappearing time Slit-lamp microscope examination was
used to record the time for corneal epithelial blisters disappearing, examination was
carried out before and 1, 2, 4 and 12 weeks after the surgery.
Corneal fluorescein staining score The healing of cornea epithelial layer was also
evaluated with fluorescein staining following Lemp 5 zones 0-3 scoring system [4]: the
center of the cornea (zone 1), superior (zone 2), temporal (zone 3), nasal (zone 4), inferior
(zone 5). Fluorescein staining of each zone can be divided into four levels: 0 (negative), 1
(punctate dot-like staining, <5 dots), 2 (punctate dot-like staining,> 5 dots), 3 (linear or
sheet-like staining). Total score of 0 to 15 points. The examination was done before and 1,
2, 4 and 12 weeks after the treatment.
OCT examination for corneal thickness Optical coherence tomography (OCT,Zeiss,
German) was used to measure the corneal thickness before surgery and 1, 2, 4 and 12
weeks postoperatively. The thickness before surgery was also used to set the depth of
needle length for ASP puncture.
Statistical analysis
SPSS 16.0 was used for data analysis. The difference between preoperative and
postoperative irrigating symptoms score, corneal fluorescein staining score and corneal
thickness was analyzed using t test.
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Results
Relieved irrigating symptoms
No cornea infection was observed during the following up period. The severity of the
irrigating symptoms was relieved weekly after treatment. The average grade score of the
eyes was 8.33 ± 2.10 before surgery, while it was reduced to 4.83 ±1.90 two weeks after
the surgery (P=0.0003) (Table 2).
Table 2 Score of the irrigating symptoms (x̄±s )
Pre-OperationPost-Operation
1 Week 2 Weeks 4 Weeks 12 Weeks
8.3±2.1 6.8±2.1 4.8±1.9 1.6±1.0 0.1±0.3
P value 0.0800 **0.0003 **0.0000 **0.0000
*P<0.05 compared to the pre-op data; **P<0.01compared to the pre-op data.
Healing of corneal epithelium and disappearing of blisters
The corneal fluorescein staining score ranged from 4 to 12 points (8.9 ±2.8) before ASP
surgery, the mean score elevated to 11.9 ± 2.5 (P=0.0100) one week after ASP surgery,
while decreased to 4.8±1.8 (P=0.0002) at the 2nd week, and remained a low level
thereafter, indicating the healing progress of cornea epithelium (Table 3). Correspondingly,
the mean time for corneal epithelial blisters disappearing was 15.6 ± 4.0 days, observed
under slit lamp microscope.
Table 3 Corneal fluorescein staining score ( x̄±s )
Pre-OperationPost-Operation
1 Week 2 Weeks 4 Weeks 12 Weeks
8.9±2.8 11.9±2.4 4.8±1.8 0.4±0.5 0.1±0.3
P value *0.0100 **0.0002 **0.0000 **0.0000
*P<0.05 compared to the pre-operation data; **P<0.01compared to the pre-operation
data.
Change of central corneal thickness
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OCT examination revealed that the pre-operative thickness of central cornea various from
640 to 1690 μm( averaged 999.3±278.0 μm) , the thickness decreased weekly as
monitored with OCT, which arrived to a relatively even level of 805.1 ±145.0μm at the 4 th
week after surgery (P = 0.0430) (Table 4).
Table 4. Change of central cornea thickness (x̄±s )
Pre-operation 1 Week 2 Weeks 4 Weeks 12 Weeks
999.3±278.0 959.5±255.0 939.3±253.9 805.1±145.0 778.3±163.1
P value 0.7180 0.5860 *0.0430 *0.0260
*P<0.05 compared to the pre-op data.
Figure 2 showed the continuous observation of a typical case pre and post-operative
manifestations recorded with slit lamp microscopy and OCT examination, with significantly
improved cornea transparency 4 weeks after treatment.
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Figure 2 Continuous observation of a typical case for ASP surgery. A 72 years old male
patient, whose left eye suffered with irrigating bullous keratopathy for one year after
phacoemulsification combined with intraocular lens implantation. The thickness of center
cornea was 1260 μm before surgery as indicated by OCT (A), and the cornea was white
with obvious edema (B). The central cornea thickness was reduced to 1100 μm two weeks
after ASP surgery and bandage contact lens wearing (C), with reduced cornea edema (D).
Four weeks later the central cornea thickness reached a stable level of 1050 μm (E), and
the cornea become even more transparent comparing to that of the pre-operation (F).
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Discussion
BK is a common complication of corneal injury, glaucoma, inflammation and intraocular
surgery, which is due to the destruction of corneal endothelial cells by various factors,
especially for those eyes with Fuchs corneal endothelial dystrophy. It has become one of
the leading indications of corneal transplantation after the advent of phacoemulsification
worldwide, particularly in developed countries [8, 18-21]. BK eyes are characterized by
permanent corneal edema and formation of blisters on the corneal epithelium.
ASP was initially used to treat patients with recurrent corneal erosion [22]; this surgical
approach can increase adhesion ability of corneal epithelial with basement membrane.
Later, ASP was used to treat BK. It is a simple, safe, effective and low-cost procedure to
relieve symptoms in patients who are not eligible for corneal transplantation [7, 9, 12, 23,
24]. The most important mechanism for ASP in treating BK is surgery-induced fibrosis. On
one hand, ASP makes the epithelial cells to form a direct contact with the substrate
stroma, this can form stable adhesion, serve to strengthen hemidesmosome and fixation
filaments. On the other hand, fibrotic scarring, as a new layer of barrier formation, hinder
the aqueous humor from leaking into the sub-epithelium, subsequently, thus corneal big
blisters gradually disappear. Corneal nerves exposure could be eliminated with the
fibrosis, thereby reducing the cornea perception and pain [25, 26].
In our study, the severity of the irrigating symptoms was relieved, the corneal epithelium
was healed and the edema and corneal thickness was reduced after treatment (Table
2,3,4, Figure 2), suggesting that ASP with bandage contact lens could treat BK patients
with troublesome symptoms effectively. Cormier in 1996 described his results about ASP
and demonstrated that the corneal thickness increased after the procedure [12]. However,
our results showed decreased corneal thickness, probably due to the addition contact lens,
which might reduce the damage to the corneal epithelium by mechanical friction of the
eyelid and thus protect the basement membrane, enhance epithelial repair and matrix
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formation of a strong adhesion. We used fine needles to perform corneal stromal puncture
surgery for 12 cases of bullous keratopathy, all patients achieved relief of irritation, corneal
edema alleviated and epithelial healed, the outcome is satisfactory.
As a conclusion, for bullous keratopathy patients with poor visual function, or those who
can’t afford for corneal transplantation, ASP surgery with bandage contact lens wearing is
an effective, convenient, reusable, economical treatment, can rapidly improve patient eye
discomfort, and has an obvious clinical practical value.
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Acknowledgements
We thank Dr. Hong Zhao, Zhitao Wang, Xiao Xiao and Jian Sun for the surgery design and
the data preparation in this paper.
Funding
The work is supported by National Natural Science Foundation of China, Grant No.
81200661, 81470606 and 81570819, by Natural Science Foundation of Hubei Province,
Grant No. WJ2017M073. 2016, and by Tongji Hospital Top Ten Translational Medical
Research Projects, Grant No. 2016ZHYX20.
Conflicts of Interest: Authors have no potential conflicts of interest to declare.
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References
1. Liarakos VS, Ham L, Dapena I, Tong CM, Quilendrino R, Yeh RY, et al. Endothelial
keratoplasty for bullous keratopathy in eyes with an anterior chamber intraocular lens. J
Cataract Refract Surg. 2013; 39: 1835-45.
2. Joyce NC. Cell cycle status in human corneal endothelium. ExpEye Res. 2005; 81:
629-38.
3. Fischbarg J, Maurice DM. An update on corneal hydration control. ExpEye Res.
2004; 78: 537-41.
4. Bourne WM, McLaren JW. Clinical responses of the corneal endothelium. ExpEye
Res. 2004; 78: 561-72.
5. Dighiero P, Guigou S, Mercie M, Briat B, Ellies P, Gicquel JJ. Penetrating
keratoplasty combined with posterior Artisan iris-fixated intraocular lens implantation. Acta
Ophthalmol Scand. 2006; 84: 197-200.
6. Pires RTF, Tseng SCG, Prabhasawat P, Puangsricharern V, Maskin SL, Kim JC, et
al. Amniotic membrane transplantation for symptomatic bullous keratopathy.
ArchOphthalmol. 1999; 117: 1291-7.
7. Gomes JA, Haraguchi DK, Zambrano DU, Izquierdo Junior L, Cunha MC, de Freitas
D. Anterior stromal puncture in the treatment of bullous keratopathy: six-month follow-up.
Cornea. 2001; 20: 570-2.
8. Paris Fdos S, Goncalves ED, Barros Jde N, Campos MS, Sato EH, Gomes JA.
Impression cytology findings in bullous keratopathy. Br J Ophthalmol. 2010; 94: 773-6.
9. Tsai TC, Su CY, Lin CP. Anterior stromal puncture for bullous keratopathy.
Ophthalmic Surg Lasers Imaging. 2003; 34: 371-4.
10. Paris Fdos S, Goncalves ED, Campos MS, Sato EH, Dua HS, Gomes JA. Amniotic
membrane transplantation versus anterior stromal puncture in bullous keratopathy: a
comparative study. Br J Ophthalmol. 2013; 97: 980-4.
Page 14
11. Paris Fdos S, Goncalves ED, Morales MS, Kanecadan LA, Campos MS, Gomes
JA, et al. Ultrasound biomicroscopy after palliative surgical procedures for bullous
keratopathy: a descriptive comparative study. Arq Bras Oftalmol. 2014; 77: 382-7.
12. Cormier G. Anterior stromal punctures for bullous keratopathy. ArchOphthalmol.
1996; 114: 654-8.
13. Thomann U, Niesen U, Schipper I. Successful phototherapeutic keratectomy for
recurrent erosions in bullous keratopathy. J Refract Surg. 1996; 12: S290-2.
14. Koenig SB. Annular keratotomy for the treatment of painful bullous keratopathy.
AmJOphthalmol. 1996; 121: 93-4.
15. DeVoe AG. Electrocautery of Bowman's membrane. Arch Ophthalmol. 1966; 76:
768-71.
16. Salleras A. Bullous Keratopathy. The Cornea (World Congress). 1965: 292-9.
17. DeVoe AG. Electrocautery of Bowman's membrane. Trans Am Ophthalmol Soc.
1966; 64: 110-22.
18. Al-Aqaba M, Alomar T, Lowe J, Dua HS. Corneal nerve aberrations in bullous
keratopathy. Am J Ophthalmol. 2011; 151: 840-9 e1.
19. Ghosheh FR, Cremona FA, Rapuano CJ, Cohen EJ, Ayres BD, Hammersmith KM,
et al. Trends in penetrating keratoplasty in the United States 1980-2005. Int Ophthalmol.
2008; 28: 147-53.
20. Tan DT, Janardhanan P, Zhou H, Chan YH, Htoon HM, Ang LP, et al. Penetrating
keratoplasty in Asian eyes: the Singapore Corneal Transplant Study. Ophthalmology.
2008; 115: 975-82 e1.
21. Al-Yousuf N, Mavrikakis I, Mavrikakis E, Daya SM. Penetrating keratoplasty:
indications over a 10 year period. Br J Ophthalmol. 2004; 88: 998-1001.
Page 15
22. Fernandes M, Moreker MR, Shah SG, Vemuganti GK. Exaggerated subepithelial
fibrosis after anterior stromal puncture presenting as a membrane. Cornea. 2011; 30: 660-
3.
23. Ljubimov AV, Saghizadeh M, Pytela R, Sheppard D, Kenney MC. Increased
expression of tenascin-C-binding epithelial integrins in human bullous keratopathy
corneas. J Histochem Cytochem. 2001; 49: 1341-50.
24. Sridhar MS, Vemuganti GK, Bansal AK, Rao GN. Anterior stromal puncture in
bullous keratopathy: a clinicopathologic study. Cornea. 2001; 20: 573-9.
25. Kenney MC, Zorapapel N, Atilano S, Chwa M, Ljubimov A, Brown D. Insulin-like
growth factor-I (IGF-I) and transforming growth factor-beta (TGF-beta) modulate tenascin-
C and fibrillin-1 in bullous keratopathy stromal cells in vitro. Exp Eye Res. 2003; 77: 537-
46.
26. Gregory ME, Spiteri-Cornish K, Hegarty B, Mantry S, Ramaesh K. Combined
amniotic membrane transplant and anterior stromal puncture in painful bullous
keratopathy: clinical outcome and confocal microscopy. Can J Ophthalmol. 2011; 46: 169-
74.